Liver Flashcards
EGD
Visual exam of esophagus, stomach, & duodenum.
TIPS procedure
Transjugular intrahepatic potto systemic shunt.
Interventional radiologic technique that reduces portal pressure.
Under conscious sedation, a stent is places percutaneously from right jugular vein into the hepatic vein.
Creates a connection between portal & systemic circulations.
Endoscopic variceal ligation (EVL)
“Banding”
Involves application of small “O” bands around the base of the varices to decrease blood supply to varices.
Cause no discomfort and pt is unaware of band presence.
Sclerotherapy
Sclerosant solution is injected into the bleeding varix or overlying submucosa.
Ballon tube tamponade
Aka Stegstaken-Blakmore tube
May be lifesaving in pts with active variceal bleeding.
3 lumens: gastric aspiration, esophageal balloon, inflated gastric balloon.
Tension is needed to be kept in place, do not leave longer than 48h
Nurses role in paracenthesis
- Explain, answer pt questions
- obtain VS, including weight
- ask pt to void prior to prevent injury to bladder.
- position pt in bed with HOB elevated
- measure drainage, record accurately
- describe collected fluid
- label & send them lab for analysis
- after physician removes cath, apply dressing to site & apply pressure; assess for leakage
- maintain bed rest
- weigh pt after paracentesis; record.
Complication of paracentesis
-Fluid & electrolyte imbalances
….increased BUN, decreased protein, & increased Hct may indicate hypovolemia
Priority problems for pts with cirrhosis.
- Excess fluid volume related to third spacing of abdominal & peripheral fluid
- Potential for hemorrhage due to portal hypertension
- Hepatic encephalopathy due to shunting of portal venous blood &/or increased ammonia levels.
Nutritional needs for pt with ascites
Low sodium diet (1-2g)
No table salt
Vitamin supplements
Low protein, high fat?
Complications of cirrhosis
- portal hypertension
- gastric & esophageal varices
- biliary obstruction
- hepatic encephalopathy
- splenomegaly
- peripheral edema & ascites
Endoscopic Retrograde Cholangiopancreatography
“ERCP”
Includes visual & radio graphic exam of liver, gallbladder, bile ducts, and pancreas to identify cause & location of obstruction
Liver transplant complications
-acute graft rejection
Occurs 4-10th day post-op (s/s: tachycardia, fever, RUQ/flank pain, diminished bile drainage, change in bile, jaundice)
-infection
Occurs at any time
-hepatic complications
Bile leakage, abscess formation, hepatic thrombosis
-acute renal failure
Caused by hypotension, antibiotics, acute liver failure, hypothermia.
Ciprofloxacin
Antibiotic Bactericidal Side effects: -N/V -diarrhea -dyspepsia -constipation -flatulence -confusion
Lactulose
Decreases ammonia forming organisms & increase acidity of bowel. side effects: -abdominal cramping -flatulence -increased thirst -abdominal discomfort
Metronidazole
Antibacterial Used in tx of anaerobic infections Side effects: -anorexia -nausea -dry mouth -metallic taste
Vaginal:
- symptomatic vaginitis
- abdominal cramps
Neomycin
Decrease ammonia forming organisms. Typically recommended when pt does not tolerate lactulose.
Norfloxacin
Antibiotic Side effects: -nausea -headache -dizziness
Salt poor albumin
Decreases complications of paracentesis such as:
- electrolyte imbalance
- increases in serum creatinine levels secondary to large shifts of intravascular volume.
Propranolol
Antihypertensive, antianginal, anti arrhythmic, anti migraine. Side effects: -diminished sexual function -drowsiness -difficulty sleeping -unusual fatigue/weakness
Rifaximin
Site specific antibiotic Side effects: -flatulence -headache -abdominal discomfort -rectal tenesmus -defecation urgency -nausea
Somatostatin
Constrict guy vessels
Spironolactone
Potassium sparing diuretic
Anti hypertensive,
Antihypokalemic
Side effects:
- hyperkalemia
- dehydration
- hyponatremia
- lethargy
Thiamine
Vitamin B1
Prevents, reverses thiamine deficiency.
Side effects:
Pain, induration, tenderness at IM injection site
Common liver transplant medications.
- cyclosporine
- fluconazole
- mycophenolate
- nystatin
- prednisone
- prenisolone
- sirolimus
- tacrolimus
- valganciclovir
Liver trauma key features
- RUQ pain with abdominal tenderness
- abdominal distention & rigidity
- guarding of abdomen
- increased abdominal pain exaggerated by deep breathing & referred to as right shoulder pain ( Kehr’s sign)
- hemorrhage/ hypovolemic shock
Functions of the liver
- regulates composition of blood, including amount of glucose, protein, fat that enter the blood stream.
- removes bilirubin, ammonia, and other toxins from blood
- processes most of the nutrients absorbed by the intestines during digestion and converts nutrients into forms that body can use.
- stores nutrients such as Vitamin A, iron, and other minerals
- produces cholesterol, & proteins such as albumin
- produces clotting factors
- metabolizes alcohol & many drugs
Bilirubin
By-product of the breakdown of hemoglobin from RBCs
Hep A
Oral-fecal, contaminated water/food.
15-50 days communicable, 1-2 was post symptoms.
S/S:
Fever, fatigue, nausea, diarrhea, anorexia, jaundice, RUQ pain
Hep B
Blood transfusion, IV drug abuse, sexual contact, hemodialysis.
48-180 days
Chronic: fulminant hep is a complication of HBV that leads to liver failure.
Hep B vaccine available
Hep C
Primarily blood contact, IV drug abusers, sexual contact (low)
14-180 days
Chronic progressive. No vaccine available
Medications impacting the liver
Pain meds; aspirin, acetaminophen, ibuprofen, naproxen, diclofenac, phenylbutazone.
Anti-seizure medications; phenytoin, valproic acid, carbamazepine, phenobarbital.
Anti-depressants; TCAs
Antibiotics; tetracyclines, sulfonamides, isoniazid, sulfamethoxazole, trimethoprim, nitrofurantoin.
Cholesterol; “statins”
Cardiovascular; Amiodarone, Hydralazine, quinidine.
4 types of cirrhosis
- Alcoholic (Laennec’s)
- Post necrotic cirrhosis
- Biliary
- Cardiac- from R side heart failure
Manifestations of liver disease
- jaundice
- portal hypertension
- ascites
- hepatic encephalopathy
- splenomegaly
- blood abnormalities
- light stools/ dark urine
- peripheral edema
- pruritis
- abdominal pain
Diagnostic tests: liver function studies
-ALT, AST, GGT: elevate
-alkaline phosphatase: present in
Liver & bones elevated in hepatitis
- CBC: low RBC, H/H, WBCs, platelets
- AFP: liver cancer marker
Diagnostic test liver function studies cont…
- prolongedPT (norm: 12-14s)
- INR: 0.8-1.2 without coag therapy
- hyponatremia
- hypokalemia, hypophosphatemia, hypomagnesmia
- bilirubin: total (2-14 umol/L)
- albumin: low (3.3-5)
- ammonia: high (0-150)
- glucose & cholesterol: abnormal
Tests: ab ultrasound, EGD, liver biopsy, CT, MRI
Stages of portal-systemic encephalopathy
Stage I- prodromal
Stage II- impending
Stage III- stuporous
Stage IV- comatose
Nursing management: ASCITES
- assess for resp. distress
- measure abdominal growth
- high fowlers position
- low protein, sodium diet
- mouth care/dehydration
- K+ sparing diuretics
- paracentesis
- salt poor albumin
- daily wt
- strict I&O
- monitor fluid & electrolytes
- perform “fluid wave” test
Portal hypertension
Normal 3 mmHg
12mmHg= esophageal rupture
Hepatic encephalopathy
Alteration in neuro status due to accumulation of ammonia
Build up of other substances such as hormones, GI toxins, other drugs
Phases of Hepatin encephalopathy
- Onset: personality changes, disturbance of awareness, forgetfulness, irritability, & confusion.
- Second: hyperreflexia, asterixis, altered hand writing, violent, abusve behavior
- Coma: + babinski, hyperactive reflexes
Cirrhosis nutrition
- Low protein (sometimes), high carb, high cal-if signs of acute hepatic encephalopathy.
- high carb, high protein, low salt
- low sodium (500mg-2g)
At first sign encephalopathy decrease protein intake (sometimes)
Why would we have a low protein diet?
Ammonia is a by-product of protein breakdown.
Contraindications to liver transplant
- Pulmonary HTN
- morbid obesity
- obstructed splanchnic blood flow,
- MELD 50 mmHg or CPP
Model for end stage liver disease
MELD
Ranges from 6 (less ill) to 40 (gravely ill). Ages 12 & over
Uses 3 routine lab results:
- bilirubin
- PT/INR
- creatinine
AST lab
Aspartate aminotransferase
5-40 units/L
ALT lab
Alanine aminotransferase
8-20 units/L
